Form FNS 683 B FNS 683 B WIC FARMERS' MARKET PROGRAM (FMNP) ANNUAL FINANCIAL AND

U.S. DEPARTMENT OF AGRICULTURE - Food and Nutrition Service

WIC FARMERS' MARKET NUTRITION PROGRAM (FMNP)
ANNUAL FINANCIAL AND PROGRAM DATA REPORT

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0584-0594. The time required to complete this
information collection is estimated to average 3.5 hours per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection.

PART A - HEADING
1. FEDERAL AGENCY AND ORGANIZATIONAL ELEMENT
    TO WHICH REPORT IS SUBMITTED

2. STATE 7-DIGIT AGENCY CODE

4. STATE AGENCY NAME AND ADDRESS

5. BASIS:

3. DUNS/UEI No.

6. REPORT YEAR
Revision ,   Closeout Report

___ CASH

___ ACCRUAL

From

To

PART B - ANALYSIS OF REPORT YEAR PROGRAM ACTIVITY
COST CATEGORY
TRANSACTION

FOOD
(A)

ADMIN.
(B)

TOTAL
(C)

7. FORMULA GRANT
8. BACKSPEND TO PRIOR YEAR
9. SUBTOTAL (7 PLUS 8)
10. GROSS OUTLAYS AND UNLIQUIDATED OBLIGATIONS FOR
    REPORT YEAR
11. PROGRAM INCOME
12. NET OUTLAYS AND UNLIQUIDATED OBLIGATIONS (10 MINUS 11)
13. RECIPIENT'S SHARE OF NET OUTLAYS AND UNLIQUIDATED
      OBLIGATIONS
14. FEDERAL PROGRAM OUTLAYS AND UNLIQUIDATED
      OBLIGATIONS (12 MINUS 13)
15. ADMIN TO FOOD CONVERSIONS
16. BALANCE (9 MINUS 14 PLUS 15)
17. BACKSPEND FROM FOLLOWING YEAR
18. RESULTS OF REPORT YEAR PROGRAM OPERATIONS
     (16 PLUS 17)

PART C - STATUS OF GRANT AWARD
19. FEDERAL OUTLAYS AGAINST THE FORMULA GRANT:
    a. FOR REPORT YEAR OUTLAYS
    b. FOR OUTLAYS OF PRIOR YEAR (BACKSPENT)
    c. TOTAL FEDERAL OUTLAYS (18a PLUS 18b)
20. FEDERAL UNLIQUIDATED OBLIGATIONS AGAINST THE
      FORMULA GRANT
21. FEDERAL OUTLAYS AND UNLIQUIDATED OBLIGATIONS
     (18c PLUS 19)
22. FEDERAL FUNDS TO BE RECOVERED (7 MINUS 20)
a. TYPE OF RATE (Place "X" in appropriate box)
23. INDIRECT
      EXPENSE

__ Provisional
b. RATE

__ Predetermined
c. BASE

__ Final
d. TOTAL AMOUNT

__ Fixed
e. FEDERAL SHARE

PART D - PROGRAM DATA
WIC RECIPIENTS SUPPORTED WITH FEDERAL AND
NON-FEDERAL FUNDS

NON-WIC RECIPIENTS SUPPORTED BY NON-FEDERAL
FUNDS

24. PREGNANT WOMEN

31. CHILDREN

25. BREASTFEEDING WOMEN

32. ELDERLY

26. POSTPARTUM WOMEN

33. OTHER

27. INFANTS

34. TOTAL NON-WIC RECIPIENTS

28. CHILDREN
29. TOTAL WIC RECIPIENTS (Line 24 THRU Line
28)
30. HOUSEHOLDS

35. TOTAL OF WIC AND NON-WIC
      RECIPIENT (Line 29 PLUS Line 34)

PROFILE OF VENDORS

FMNP ISSUANCE AND REDEMPTION SUMMARY

36. NUMBER OF AUTHORIZED FARMERS

40. VALUE OF FOOD BENEFITS ISSUED
      (FEDERAL)

37. NUMBER OF AUTHORIZED FARMERS'
      MARKETS

41. VALUE OF FOOD BENEFITS REDEEMED
      (FEDERAL)

38. NUMBER OF AUTHORIZED FARM OR
      ROADSIDE STANDS, IF ANY
39. TOTAL NUMBER OF AUTHORIZED FARMERS,
FARMERS' MARKETS, AND ROADSIDE
STANDS

42. VALUE OF FOOD BENEFITS ISSUED
      (NON-FEDERAL)
43. VALUE OF FOOD BENEFITS REDEEMED
      (NON- FEDERAL)

PART E - OTHER

REMARKS

CERTIFICATION:

TYPED NAME AND TITLE OF CERTIFYING OFFICIAL

I CERTIFY TO THE BEST OF MY KNOWLEDGE AND BELIEF THAT
THIS REPORT IS CORRECT. AND THAT ALL OUTLAYS AND
UNLIQUIDATED OBLIGATIONS ARE FOR THE PURPOSES SET
FORTH IN THE AWARD DOCUMENT.

SIGNATURE
TELEPHONE NUMBER

DATE

STAMP/CERTIFY DATE

LAST UPDATED BY

LAST UPDATED ON